Download "Emergency Trip Denial Appeal Letter" Word Document
Appeal Letter Displayed for Your Convenience
Health Symphony Appeal Letter
For Emergency Trip Denial
Your name and address
Address of Claims review department
RE: Name of Insured:
Plan ID #:
Dear Claims Review Department:
I am writing to you in regards to a claim submitted by [Medical Provider] for [patient]. The charges were rendered on [Date] and totaled [Claim dollar total]. [Health Plan] has denied payment stating that the Emergency Transportation was not covered.
[Patient] was airlifted in an Emergency Helicopter from [Facility/Hospital Name] on [Date of Service] to [Other Facility/Hospital Name] as a result of [list your accident]. This required the [Patient] to be taken to an emergency facility which was the only one available to provide the treatment required.
There was not an opportunity for [Facility/Hospital Name] or the patient to obtain prior authorization from the health plan prior to receiving emergency treatment. Once [Patient] was stabilized on [Date] we did speak with a health plan representative to request an authorization for the emergency transportation. We have since been told that the [Patient] had to be seen at a designated hospital, but due to the emergency situation we had to choose the nearest and only available emergency room facility that could handle and treat the patient.
As this visit was medically necessary, I am requesting that the health plan override its denial of this claim. Medicare, which is usually considered the standard in the health care industry, will pay for emergency ambulance transportation in a helicopter if the health condition of the patient requires immediate and rapid ambulance transportation that ground transportation cannot provide. I am requesting that [health plan] also consider and pay for this claim that is outstanding. I have included a statement of medical necessity from the emergency physician who is also prepared to provide a rebuttal to your decision.
Thank you for your time and consideration.
Statement of medical necessity from the medical provider